Commercial RADV Audit Survival Guide - Cognisight, LLC · Commercial RADV Audit Survival Guide M a...
Transcript of Commercial RADV Audit Survival Guide - Cognisight, LLC · Commercial RADV Audit Survival Guide M a...
©2015 Cognisight, LLC
Presented by: Kim Browning, CHRS, PMP, CHC Executive Vice President
Commercial RADV Audit
S u r v i v a l G u i d e
M a y 1 3 , 2 0 1 5
©2015 Cognisight, LLC
Today’s Agenda 2
Commercial RADV at a Glance
Components
Best Practices
Choosing Best Medical Record
Choosing Best Vendor
o What to Look for
o What to Avoid
Staff Support
Submitting Supplemental Dx
Q & A
Appendices
o IVA Rules
o Sample Stratum
o SVA Scope
o Payment Adjustments
RA
DV
Su
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Commercial RADV at a Glance:____ Why IVAs Are Necessary
Risk adjustments in the commercial market are zero based
o For every winning issuer, there’s a losing issuer
Better risk scores than your competition’s influences a better “transfer payment”
As a result, there is an incentive to game the system
HHS instituted Initial Validation Audits (IVAs) for every issuer, every year as a deterrent to gaming the system
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Commercial RADV at a Glance:____ Risk Adjustment Data Validation
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Six-stage process proposed to begin in 2015
Sample Selection
Initial Validation Audit (IVA)
Secondary Validation Audit (SVA)
Error Estimation
Appeals
Payment Adjustments
Independent Vendor
HHS
HHS or Designees
HHS or Designees
HHS
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Components:____ IVA Services
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Analytics
o Triage validation
o Missing HCCs
Chart retrieval HCCs
o EMR
o Paper (fax/mail)
o Uploads
Bi-directional review
o Dx verification and new dx capture
Demographic review
o Demographic verification and new dx capture
Quality control (re-review of information)
Status and results reporting
o Status to client
o Reporting to HHS
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Best Practices:____ Initial Validation Audits
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Consider reusing internal analytics, if available
o As long as analytics meet criteria
Reuse as many existing charts as possible
Choose the best medical record analytics identifies—but be willing to pursue alternate charts if the best medical record isn’t successful
Consider onshore coders only
o HIPAA doesn’t protect data outside US
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Best Practices:____ IVAs, cont.
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Experience with issuer enrollment auditing and tying back to ensure vendor has source documentation, when necessary
o More than simply member eligibility
o Verify items that affect risk adjustment payment
o Mass programmatic changes
Determine what can be done now
o Preassemble your team
o Begin set up of SFTP test file exchanges with vendor(s)
o Determine enrollment sources
o Plan out different scenarios
o Anticipate needs for BAAs and third party data release agreements and secure in advance
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Best Practices:____ SVA Readiness
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The best SVA defense is a great IVA offense
o Bulletproof the IVA
Be armed with guidelines, coding clinic, and other reference materials
Expect shared learnings
Be timely with additional requests
Respect differences
o New 50 Shades of Grey
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Run Analytics
Find Matching
Claim/ Chart
Review Yes?
Is There a Missed
Dx?
No
Choosing Best Medical Record:____ Missed Diagnosis
Record for IVA
Analytics must o Select eligible provider and procedure code o Weight providers to each to each dx
Obtain Medical
Record(s)
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Choosing Best Medical Record:____ Validation
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Medical Record Tied to Claim
Obtain Medical
Record(s) Validate?
Good Medical Record
Yes?
No?
Initiate Alternate
Pursuit
No?
Other Claims
with Dx? Yes?
DOS = Enrollme
nt Period?
Eligible Provider?
Secure Medical Record
Record Pass
Record Fail
Record Fail
Review
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Knowledge and understanding of rules o Has your vendor read, digested, and operationalized rules?
o Can vendor explain how rules are applied to audit scope?
Prior audit experience o Has vendor previously conducted any Medicare or Medicaid risk
adjustment audits?
o How recently have they completed the audit?
o Do they have “bi-directional” audit experience (i.e. capturing missing diagnoses and verifying existing diagnoses)?
Audit staff o Can vendor document their auditors credentials?
o Does vendor outsource any of their work to other firms? • To be expected due to episodic/seasonal nature of the RADV
Choosing Best IVA Vendor:____ What to Look For
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Quality control efforts o What percent of captured information is re-reviewed?
• Varies between 10–100%, depending on vendor
Reusability o Is vendor willing to re-use prior analytics?
Chart retrieval o Does vendor offer chart retrieval?
• If so, how many charts are they willing to retrieve?
Fee structure o Are there any hidden fees?
o Does vendor support audit through completion of SVA?
o Does vendor charge implementation or reporting fees?
Choosing Best IVA Vendor:____ What to Look For, cont.
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Testing
o As part of your selection process, “test” vendor
• Review results and compare vendors
Process improvement
o After audit completion, will vendor have provided info to help issuer address any risk points?
o Does vendor understand demographic portion of IVA and have experience in enrollment auditing?
• Can be more than one transaction
o Does vendor validate based on coding guidelines?
• Clinical arguments will not stand
Choosing Best IVA Vendor:____ What to Look For, cont.
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Waiting too long to select your vendor
o Limited number of strong vendors; risk of being left to choose from second tier
General audit versus risk adjustment audit experience
o Risk adjustment audit experience in particular will help IVA vendor be successful
Choosing lowest priced vendor based on price only
o The financial impact of a poorly run IVA isn’t worth the risk
Not asking what’s outsourced
Vendors that can’t execute end-to-end
o Increased risk points if too many components are outsourced
Choosing Best IVA Vendor:____ What to Avoid
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Choosing Best IVA Vendor:____ Given the Gift of Time
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Concurrent chart reviews
o Take learnings and apply to risks prior to IVA
Consider internal sample/audit
o Be sure you have the right staff members/level involved
o Preassemble your audit team
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Choosing Best IVA Vendor:____ Given the Gift of Time, cont.
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Validation awareness
o Average dx to verify 1.60–2.25
o Validated dx 43–44%
o Invalid dx’s 56–57%
• No documentation found 78–82%
• Invalid codes 10–13%
• Provider/chart mismatch 8%
• Top HCCs
11 Colorectal, breasts (age <50), and prostate
21 Diabetes without complications*
12 Breast ( age 50+) and prostate
82 Drug dependence
9 Lung, brain, and other severe cancers*
183–188 Kidney transplant, ESRD, and CKD stages 4 and 5
130 CHF*
20 Diabetes with complications
*HCCs also frequently validated
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IVA
SVA
On
Standby
On
Standby
Staff Support____ 17
Not Expected
Not Expected
Not Expected
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Submitting____ Supplemental Diagnosis
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If conducting chart review for missed dx, must also look for incorrect dx
o Ideally validate what went through in a claim encounter
• If correct dx, no further action required
• If incorrect dx, delete submission via supplemental file
o Ensure encounter was accepted
• If unsure, submit delete
All submissions and deletes must tie to a claim
o When it doesn’t; have a process to research and close the discrepancies
Supplemental files are “in scope” for Risk Adjustment Data Validation (RADV)
File submission
o Tightly follow ICD specs
• Maintain current version
o 16 digit insurance issuer number has to match original claim
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Q&A____
For more information, please contact:
Kim Browning [email protected] 585.662.4215 www.linkedin.com/in/kimbrowning1
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Appendix:____ IVA Rules
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All HIX issuers will be audited annually o If operating in multiple states, RADV conducted in each state
200 member sample for ≥1,000 members o 100 member sample for 100–999 members
• Guidance pending for <100
o 2/3 driven by HCC, 1/3 by demographics
o Sample is combined on/off the exchange
Audits are bi-directional o Substantiate submitted HCCs and identify missing HCCs
(including demographic sample)
IVA cannot be HIX risk adjustment vendor
HCC
Demographics
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Issuers must provide HHS the IVA entity’s name, qualifications, and relationship to issuer
o Deadline to provide above has been suspended indefinitely
Issuers cannot waive obtaining an IVA
Data pulled from EDGE server used for sample
IVA provides audit outcomes to HHS
o Not to the issuer
o Not expected to be via EDGE server
Appendix:____ IVA Rules, cont.
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IVA entity shall be capable of performing audit and ensuring accuracy of risk adjustments in accordance with standards
Able to complete IVA and submitted IVA findings to HHS in manner and timeframe specified by HHS
Free of conflicts of interest
Must use CCS’, CPCs, or RHITs
For every incorrect HCC, a secondary review has to be conducted by a senior person
Appendix:____ IVA Rules, cont.
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Appendix:___ Sample Stratum
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1–3 low, medium, high adults with at least 1 HCC
1–3 low, medium, high children with at least 1 HCC
1–3 low, medium, high infants with at least 1 HCC
10 demographic sample
Remember, all stratum have to also be audited for missing HCCs
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Appendix:___ SVA Scope
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SVA will be done by HHS or designated entity
o Will be a subsample of the IVR unless the difference between the samples is too large
• If so, a larger sub-sample will be drawn
o HHS considering a pair-wise evaluation to establish a statistical evaluation between the IVA and SVA
o HHS is evaluating ways to expedite the SVA process
o 95% Inter Rater Reliability (IRR)
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Appendix:___ Payment Adjustments
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Safe harbor for Benefit Years 2014 and 2015
Subject to
o Fraud, Waste, and Abuse Act
o False Claims Act